Please complete all fields so your concern may be directed to the proper university officials.

(In compliance with federal regulations, UI&U will maintain a log of submitted forms.)

Full Name (First Last)

Name while enrolled

Program and Major

Mailing address

Address 2

City

State

Zip Code

Your Preferred Email Address

Telephone

Union ID

Last Date of Attendance

Preferred Method of Contact

Preferred Method of Contact

Email

Phone

U.S. Mail

First date on which the events or issues occurred

*

Name(s) of the person(s) involved

Please describe your concern in detail. Include the names of persons, locations, and dates involved. If this concern regards specific person(s), please list their names and titles.

*

What attempts have you made to resolve this concern up to now? Please state who you contacted and what transpired.

Why do you think the concern was not able to be resolved in your prior attempts?

What resolution would you consider fair? What resolution do you seek?

Is there any other information you would like to provide?

Optional: Attach documents in support of your concern here.

Attachment 1

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Attachment 2

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Attachment 3

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Certification

I certify that the above information is true and correct to the best of my knowledge and belief. I grant permission for this concern to be forwarded to UI&U officials for purposes of investigation and response. By signing and submitting this concern, I authorize Union Institute & University to follow up on this issue as needed. I understand that Union Institute & University may contact me for additional information. Please type your name below.